Within our Trust we endeavoured to ensure the safety and quality of care for the acutely ill patient . Setting standards of care from the basics of observations, to training of acute care skills for nurses and medical staff within the wards, we have ensured appropriate and timely recognition and response of the acutely ill patient. Implementing an electronic system for recording observations and automatically alerting the correct personnel, with an appropriate graded response as per the trust Early warning score policy and NICE guidance recommendation. With the review of all emergency bleeps by a core multidisciplinary team the accountability of care sits firmly with the parent teams of the patients, with support in care and processes from across the organisation. These initiatives have over the last 4 years established a safer organisation for our acutely ill patients and the consolidation of the NICE guidance CG 50 within the trust.
Central Manchester University NHS Hospitals NHS Foundation
Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?
The aim of the initiative was to 'transform acute care' within our organization and ensure that we delivered a high standard of care and safety for the acutely ill patient in hospital. Firstly, we wanted to ensure that we had a standard of care to all patients throughout the trust in prompt and effective recognition, interpretation and treatment should they deteriorate. Thus we wanted to set standard of how, why and when to take observations. With set guidance on who could do then and with what competencies. We also set standards for the skills in early recognition and response to the deteriorating patient. Courses, training and assessment for all nurses and medical staff are run to enable this. Competencies were also matched from the core competencies from the DOH ensured that all skills required are available day and night across the organisation. We also wanted to ensure that the well established Early Warning Score (EWS) process is complied with and following a successful trial, we began the trust wide implementation of the automatic observation and alerting system. Finally, we became concerned that we did not understand fully the accurate numbers or triggers for cardiac arrests in our hospitals. In order to improve our care processes we used this group of patients to investigate the care delivered in the period leading up to their cardiac arrest. We wanted to identify learning outcomes that could come from a close review to observe, identify themes and share process changes and action plans using a high level view. A group of clinicians was established in October 2009 to review all emergency calls on a weekly basis. For those requiring further investigation, the medical and nursing team supervising the care of the patients present back the patients with both areas of good practice and areas where alternative actions or alternative methodology might have prevented the call if appropriate, defining if the case is potentially avoidable. There were four key objectives: Observation standard setting - All staff conducting observation sets were to be taught, assessed and signed off as competent to do so. Acute care skills - standards were set that all qualified nursing staff within each ward are expected to attend an acute illness management (AIM) course which teaches and assess the competency of the nurse in assessment skills and treatment of the acutely ill patient. A standard was also set that within the wards on each shift there is a nurse who is able to insert venous cannulae, and prescribe fluids in an acutely dehydrated patient and has attended an acute care course for additional skills. This enabled the delivery of the 'primary responder' as per the core competencies from NICE and the DOH stated. Junior medical staff also attend the AIM course and the senior medical staff are also undertaking a standard course in recognition and response the deteriorating patient. There was analysis of the core competencies from the DOH was undertaken by a group of nursing and medical staff to ensure that the skills were held by different members of the multidisciplinary team throughout the organisation. Patientrack implementation - Following an 18 month trial with successful results; improvement of length of stay, reduction in critical care bed days and timeliness of observations, the automated system has begun trust wide implementation. The system allows observations to be inputted into hand held PDA's, the calculation of the EWS and an automatic alert is raised to the correct personnel as per the local Early warning score protocol. Emergency bleep meeting - A multidisciplinary group was formed to investigate and analyse every emergency bleep call made and incidents relating to recognition and response. This multidisciplinary core group with an interest in patient safety meet weekly to discuss the cases. The meetings have identified themes altering processes and guiding training.
The recording, recognition and response to the acutely deteriorating hospital patient has been a longstanding patient safety concern. Numerous august bodies have published data reporting that: - 60% of ICU admissions are deemed to have received suboptimal care prior to admission to ICU 21% to 41 % avoidable (McQuillan et al. BMJ 1998). - 50% of cardiac arrests had premonitory signs prior to the event (Smith etc al 1995) - 40% of patients deemed not to have received prompt or appropriate care prior to admission to ICU (NCEPOD 2005). - Suboptimal ward care contributed to 35% of ICU deaths (NCEPOD 2005) - 21% of cases reviewed had no observations taken for a prolonged period before death (NPSA 2007). - Despite recording vital signs there was a failure to recognise clinical deterioration and/or no action in 47% of cases (NPSA 2007). - Deterioration was recognised and assistance sought but significant delays occurred in 11% of cases (NPSA 2007). In keeping with this data cardiac arrests have been cited as a potential marker of poor quality care. We previously developed and trialled an IT application - Patientrack - that accurately calculates our 'track and trigger' and alerts the appropriate responder. This referral continues until the patient improves. This work has previously demonstrated improved patient safety gains and reduced risks to patients. Whilst we had agreed on a Trust wide implementation of Patientrack we felt that an IT system is only as good as the system it supports and so set about a number of strategies to improve the quality of care for our acutely ill patients.
The main change was a cultural and trust wide recognition of the issues and work towards a common goal. Within the process there were individual objectives that required different work to be undertaken; Once the standards were set for observations and acute care skills, we had to alter policy and ensure that there were resources available to facilitate the teaching and implementation of the changes. Audits, observational reviews, competency assessments and teaching commenced for all relevant qualified and non- qualified nursing staff this of course had to include temporary staff (agency) , medical staff, from FY1s progressing onwards and registrars are presently having training in relation to the recognition and response to the acutely ill patient. For the implementation of the patientrack system, we have created and acute care team, with a lead nurse, two educators and close links to the IT project manager and administrator. There is also a clinical lead who supports the process and roll out. The acute care standards above were set for each ward prior to the acute care team entering to undertake the training of all ward nursing and medical staff in the electronic system. The two have gone hand in hand to ensure that clinical judgment is overall the most important with the automatic alerting ensuring at the EWS process is followed. We already knew that out Trust had an average of 5- 8 emergency bleep calls (2222 calls) per week. In order to improve our care processes with existing resources to create the core team. We wanted to identify learning outcomes that could come from a close review to observe, identify themes and share changes and action plans using a high level view. These themes and action plans have been shared across the organisation and helped guide training and policy.
The largest result has been the change in culture within the organisation. The weekly emergency bleep meetings have become embedded in the organisation and have a strong 'no blame' ethos. Within the process we have reviewed over 400 cases and brought to the meeting over 100. We have highlighted themes that we have responded to and addressed. For example, at the start of the project the recognition and management of sepsis was a key theme. Following a system wide training package this now hardly features as an issue at the meetings. This process has also instigated a significant number of changes to both local and Trust wide policies for example, oxygen therapy, transfers and DNR policies. Importantly the reduction in cardiac arrests has been significant. Since our start in mid 2009 we have been successful in all of our key measures of improvement. We have implemented Patientrack into the surgical division and have started now on the medical division. This enables us to ensure the appropriate recording, recognition and response to patient observations. Moreover, we know that these have been done by staff signed off as competent to do so. Nearly all scheduled shifts have first responders on them. Local changes in individual wards have occurred, but the nature of the joined up strategy is that this is about shared learning so the ideas and changes are shared on the website and a monthly letter is sent to all staff to look at the suggestions and changes that have worked in certain areas. Staff now volunteer to bring cases back when they feel there are issues they want to raise.
Starting with the basics was key to the strategy and enabled a reassurance to all ward managers that observations were being performed to an adequate standard. The setting of standards for acute care skills also gave reassurance to all levels that the front line staff have skills in recognition and response of the acutely deteriorating patients. A multidisciplinary team approach has been an effective, enjoyable and extremely useful approach to give a thorough and full assessment of each case, also ensuring that changes can occur quickly and effectively. Because the approach must cover the whole organisation it is essential to have executive lead to ensure Trust ownership and so that all staff teams understand the importance of the process and why it is required. This is not an insignificant administrative burden and dedicated administrative support would be useful.
Lead Nurse Acute Care Team
Central Manchester University NHS Hospitals NHS Foundation
Is the example industry-sponsored in any way?